Transcript In the Name of God

In the
Name of
God
Pericardial disease
Dr. Mirdamadi
Cardiologist,Fellowship of
Echocardiography
Pericardium
• The normal pericardium is a double-layered
sac
• the visceral and parietal pericardium that is
separated by a small quantity (15–50 cc) of
fluid.
pericardial functions
• 1. Prevents sudden dilation of the cardiac chambers,
especially the right atrium and ventricle, during
exercise and with hypervolemia.
• 2.Restricts the anatomic position of the heart
• 3.Minimizes friction between the heart and
surrounding structures
• 4. Prevents displacement of the heart and kinking of
the great vessels
• 5. Retards the spread of infections from the lungs and
pleural cavities to the heart.
Acute Pericarditis
Clinical Classification
I. Acute pericarditis (<6 weeks)
A. Fibrinous
B. Effusive (serous or sanguineous)
II. Subacute pericarditis (6 weeks to 6 months)
A. Effusive-constrictive
B. Constrictive
III. Chronic pericarditis (>6 months)
A. Constrictive
B. Effusive
C. Adhesive (nonconstrictive)
Etiologic Classification
• I. Infectious pericarditis
A. Viral (coxsackievirus A and B, echovirus,
mumps, adenovirus, hepatitis, HIV)
B. Pyogenic (pneumococcus, streptococcus,
staphylococcus, Neisseria, Legionella)
C. Tuberculous
D. Fungal (histoplasmosis, coccidioidomycosis,
Candida, blastomycosis)
E. Other infections (syphilitic, protozoal, parasitic)
• II. Noninfectious pericarditis
A. Acute myocardial infarction
B. Uremia
C. Neoplasia
1. Primary tumors (benign or malignant,
mesothelioma)
2. Tumors metastatic to pericardium
(lung and breast cancer, lymphoma, leukemia)
D. Myxedema
E. Cholesterol
F. Chylopericardium
G. Trauma
1. Penetrating chest wall
2. Nonpenetrating
H. Aortic dissection (with leakage into pericardial sac)
I. Postirradiation
J. Familial Mediterranean fever
K. Familial pericarditis
L. Acute idiopathic
M. Whipple's disease
N. Sarcoidosis
• III. Pericarditis related to hypersensitivity or
autoimmunity
A. Rheumatic fever
B. Collagen vascular disease
C. Drug-induced
D. Post-cardiac injury
1. Postmyocardial infarction (Dressler's syn.)
2. Postpericardiotomy
3. Posttraumatic
Definition
• Acute Pericarditis defined as symptoms or
signs resulting from pericardial inflammation
of no more than 1-2 weeks
• The majority of causes is idiopathic
• Most cases of acute idiopathic pericarditis are
viral but testing for specific virus is not routine
• Acute pericarditis almost always presents with chest pain
• The pain can be severe.
• It is almost always pleuritic. It is not similar to myocardial
ischemia.
• Pericardial pain typically has a relatively rapid onset
• It is most commonly substernal but can be centered in the
left anterior chest or epigastrium.
• Left arm radiation is not unusual. The radiation is to the
trapezius ridge, which is highly specific for pericarditis.
• Pericardial pain is relieved by sitting forward and
worsened by lying down.
• Associated symptoms : dyspnea, cough, and
hiccoughs.
• history of symptoms suggesting a viral syndrome
is common.
• It is important to review the past medical history
for clues to specific diagnoses. A history of
cancer or an autoimmune disorder, high fevers
with shaking chills, rash, or weight loss should
alert the physician to specific diseases that can
cause pericarditis.
Differential Diagnosis
• pneumonia or pneumonitis with pleurisy (which may
coexist with pericarditis),
• pulmonary embolus or infarction,
• costochondritis,
• gastroesophageal reflux disease.
• myocardial ischemia or infarction
• aortic dissection
• intraabdominal processes
• pneumothorax
• herpes zoster pain before skin lesions appear.
• Acute pericarditis due to recent silent MI.
Physical Examination
• Patient is uncomfortable and anxious and may
have low grade fever and sinus tachycardia.
• The only abnormal physical finding is the friction
rub caused by contact between visceral and
parietal pericardium.
• It consists of three components corresponding to
ventricular systole, early diastolic filling, and atrial
contraction .
• The rub is usually loudest at the LSB and is best
heard with the patient leaning forward.
• It is often dynamic, disappearing and
returning during short periods.
• Thus, it is often rewarding to listen frequently
to a patient with suspected pericarditis who
does not have an audible rub initially.
Laboratory Testing
Electrocardiography
• ST-segment elevation in all leads except aVR and often
V1.
• The ST segment is usually coved upward and resembles
the hyper acute MI(differentiation with more extensive
lead involvement in pericarditis and the presence of
reciprocal ST depression in ischemia.)
• However, ST elevation in pericarditis sometimes
involves a smaller number of leads
• Somtimes, the ST segment is similar to early
repolarization. Here again, pericarditis usually involves
more leads than typical early repolarization
As with the rub,
electrocardiographic changes
can be dynamic.
• PR segment depression is also common .
• PR depression can occur without ST elevation
and be the initial or sole ECG manifestation of
acute pericarditis.
• In some, the ECG reverts to normal during
days or weeks.
• In others, the elevated ST segment progresses
to ST-segment depression and T wave
inversions in leads with upright QRS
complexes.
• These changes can persist for weeks or even
months .
In patients presenting late after the
onset of symptoms, these findings
can be difficult to distinguish from
ischemia
Laboratory Data
• Modest elevations of the white blood cell
count with mild lymphocytosis
• Elevated creatine kinase MB fraction or
troponin I values
• Serum ANA evaluation in young woman is
recommended.
• The CXR is usually normal in uncomplicated
acute idiopathic pericarditis but pulmonary
disease,TB,malignancy or pericardial effusion
may be detected by CXR
Echocardiography
• Echo is normal in the most patients .
• The main reason for it is to exclude silent
effusion. Most patients do not have effusions,
but small ones are fairly common .
• Moderate or larger effusions are unusual and
may signal a diagnosis other than idiopathic
pericarditis.
• Echo is also useful to rule out associated
myocarditis.
Treatment
• Acute idiopathic pericarditis is a self-limited
disease without significant complications or
recurrence in 70% to 90% of patients.
• Treatment with NSAIDs should be initiated
• Ibuprofen (600 to 800 mg orally three times
daily) with discontinuation if pain is no longer
present after 2 weeks.
• Patients who respond slowly or inadequately
to NSAIDs may require supplementary
narcotic analgesics to allow time for a full
response or a course of colchicine.
• Colchicine is administered as a 2- to 3-mg oral
loading dose followed by 1 mg daily for 10 to
14 days
• Poorly responding patients have typically been
treated with short courses of corticosteroids.
• However, corticosteroids should be avoided as
they appear to encourage recurrences.
• Prednisone 60 mg orally daily for 2 days with
tapering to zero during a week.
Cardiac Tamponade
• The accumulation of fluid in the pericardial
space in a quantity sufficient to cause serious
obstruction to the inflow of blood to the
ventricles results in cardiac tamponade.
• This complication may be fatal if it is not
recognized and treated promptly.
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The most common causes of tamponade :
neoplastic disease
idiopathic pericarditis
renal failure.
Tamponade may also result from bleeding into
the pericardial space after cardiac operations,
trauma, and treatment of patients with acute
pericarditis with anticoagulants.
• The three principal features of tamponade
(Beck's triad) :
• Hypotension
• Soft or absent heart sounds
• Jugular venous distention with a prominent x
descent but an absent y descent
• The quantity of fluid necessary to produce
tamponae may be as small as 200 mL when
the fluid develops rapidly or >2000 mL in
slowly developing effusions .
• Tamponade may also develop more slowly,
and in these circumstances the clinical
manifestations may resemble those of heart
failure, including dyspnea, orthopnea, and
hepatic engorgement
Paradoxical Pulse
• presence of cardiac tamponade consists of a
greater than normal (10 mmHg) inspiratory
decline in systolic arterial pressure
• Since both ventricles share a tight
incompressible covering, the inspiratory
enlargement of the right ventricle in cardiac
tamponade compresses and reduces left
ventricular volume
• leftward bulging of the IVS further reduces
the left ventricular cavity as well.
• Thus, the normal inspiratory augmentation of
right ventricular volume causes an
exaggerated reciprocal reduction in left
ventricular volume.
• respiratory distress increases the fluctuations
in intrathoracic pressure, which exaggerates
the mechanism just described.
• RV MI may resemble cardiac tamponade with
hypotension, elevated JVP, an absent y
descent in the JVP, and, occasionally, pulsus
paradoxus.
Differential Diagnosis of
Paradoxical Pulse
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constrictive pericarditis
hypovolemic shock,
acute and chronic obstructive airway disease
pulmonary embolus.
RV MI
Electrocardiographic
abnormalities
• 1.reduced voltage
• 2.electrical alternans
• Electrical alternans caused by anteriorposterior swinging of the heart with each
heart beat.
Treatment
• Patients with acute pericarditis should be
observed frequently for the development of
an effusion
• if a large effusion is present, the patient
should be hospitalized and pericardiocentesis
carried out or the patient should be watched
closely for signs of tamponade
Chronic Constrictive
Pericarditis
• Constrictive Pericarditis(CP)results of healing
a fibrinous or serofibrinous pericarditis or the
resorption of a chronic pericardial effusion
• The latter gradually contracts and forms a firm
scar, which may be calcified, encasing the
heart and interfering with filling of the
ventricles
Etiologies
• CP may follow acute or relapsing viral or idiopathic
pericarditis
• Trauma with organized blood clot
• Cardiac surgery of any type
• Mediastinal irradiation
• Purulent infection,TB
• Histoplasmosis
• Neoplastic disease (especially breast cancer, lung
cancer, and lymphoma)
• Rheumatoid arthritis, SLE
• Chronic renal failure with uremia treated by dialysis.
• The basic abnormality in this patients is the
inability of the ventricles to fill because of the
limitations imposed by the rigid, thickened
pericardium
• myocardial function is normal or only slightly
impaired
• However, the fibrotic process may extend into
the myocardium and cause myocardial
scarring and atrophy
• In constrictive pericarditis, JVP display an Mshaped contour, with prominent x and y
descents.
• The y descent, which is absent or diminished
in cardiac tamponade, is the most prominent
deflection in constrictive pericarditis
• The usual presentation consists of signs and
symptoms of right-sided heart failure.
• Include lower extremity edema, vague
abdominal complaints, and passive hepatic
congestion.
• As the disease progresses, hepatic congestion
worsens and can progress to ascites, anasarca,
and jaundice due to cardiac cirrhosis.
• In end-stage , the effects of a chronically low
cardiac output are prominent, including
severe fatigue, muscle wasting, and cachexia.
• Other findings include recurrent pleural
effusions and syncope.
• CP can be mistaken for any cause of rightsided heart failure
• As well as end-stage primary hepatic disease.
venous pressure is not elevated in the latter
circumstance.
Physical Examination
• markedly elevated JVP with a prominent,
rapidly collapsing y descent.
• This, combined with a normal x descent,
results in an M- or W-shaped contour
• The cervical veins are distended and may
remain so even after intensive diuretic
treatment, and venous pressure may fail to
decline during inspiration (Kussmaul's sign).
• The latter may occur in chronic pericarditis ,
tricuspid stenosis, right ventricular infarction,
and restrictive cardiomyopathy.
• The pulse pressure is normal or reduced.
• In 1/3 of cases, a paradoxical pulse can be
detected.
• Congestive hepatomegaly is pronounced and
may impair hepatic function and cause
jaundice
• ascites is common and is usually more
prominent than dependent edema
• The apical pulse is reduced and may retract in
systole (Broadbent's sign).
• The heart sounds may be distant
• Pericardial knock, in early diastole occurs with
the abrupt cessation of ventricular filling.
• A systolic murmur of tricuspid regurgitation
may be present.
The ECG frequently displays :
• Low voltage of the QRS complexes
• Diffuse flattening or inversion of the T waves.
• Atrial fibrillation is present in about one-third
of patients.
• The CXR shows a normal or slightly enlarged
heart
• Pericardial calcification is most common in
tuberculous pericarditis.
• Pericardial calcification may,occur in the
absence of constriction.
More accurate modalities
• Echocardiography
• MRI
• CT-scan
Treatment
• Pericardial resection is the only definitive
treatment of constrictive pericarditis and
should be as complete as possible. Dietary
sodium restriction and diuretics are useful
during preoperative preparation.